Maria Cândida Rizzo

Inhaled corticosteroids in the treatment of respiratory allergy: safety vs. efficacy

OBJECTIVE Review the molecular mechanisms of action, efficacy, and potential side effects associated with inhaled corticosteroids (ICS) in children with persistent asthma. SOURCES Articles in English from MEDLINE. The following terms were used: corticosteroids, inhaled corticosteroids, asthma, children, beclomethasone, fluticasone, budesonide, ciclesonide, growth, adrenal insufficiency, bone mineral density, and oral candidiasis. Treatment guidelines, review articles, controlled trials, meta-analyses, and systematic reviews evaluating the efficacy and the adverse events of treatment with ICS were selected. SUMMARY OF THE FINDINGS In vivo and in vitro studies show that the available ICS have different pharmacokinetic and pharmacodynamic properties that result in different action potentials. ICS also differ as to the systemic and local side effects. The bioavailability of these products is essential in order to determine the incidence of side effects. In general, ICS are capable of controlling asthma, reducing the number of exacerbations, medical consultations, hospitalizations, and the need of oral corticosteroid (applications) bursts. Improvement can also be seen in pulmonary function, especially in patients with recent onset asthma. The most documented adverse effect is transitory decrease of growth rate. CONCLUSIONS ICS are the main anti-inflammatory agent used to treat persistent asthma. When administered in low doses, they seem to be safe and effective. Patient monitoring allows for early detection of possible side effects associated with ICS.

Corticosteroids (inhaled and/or intranasal) in the treatment of respiratory allergy in children: safety vs. efficacy

BACKGROUND Topical administration of Corticosteroids (CS) can reduce the total dose of CS required to treat the patient and minimize side effects. Topical CS is extremely effective and has an excellent safety profile. Nonetheless, care must be taken when multiple sites such as lungs, nose and skin are being treated. CS mechanisms of action on the inflammatory process are complex. The aim of this study is to review such mechanisms and the adverse events secondary to it. METHODS Review English database (Embase, PubMed, Scielo) searching words: CS, adverse events, inhaled CS, intranasal CS, and children. RESULTS There is a classic mechanism involving a genomic effect of CS and a non-genomic effect, independently of gene transcription process. This mechanism acts by reducing mucosal blood flow in the asthmatic airways. Second-generation topical CS is the treatment of choice in allergic diseases control because of their good anti-inflammatory activity, poor absorption and first-pass hepatic metabolism. When comparing different CS, it is important to compare therapeutically equivalent doses. Although topical CS reduces systemic side effects, local and even systemic side effects can occur. Many factors affect the amount of drug that reaches the lung, including inhaler technique and inhaler type, fine particle dose and particle distribution. CONCLUSION Most patients with allergic diseases respond to CS treatment, but there is a small subset of them whose response is unsatisfactory even with high doses of CS. They are classified as corticosteroid-resistant asthmatics. Pro-inflammatory cytokines appear to up regulate the expression of GRb that has been associated with CS resistance.

Corticosteróides inalados no tratamento da alergia respiratória: segurança versus eficácia

OBJECTIVE: Review the molecular mechanisms of action, efficacy, and potential side effects associated with inhaled corticosteroids (ICS) in children with persistent asthma. SOURCES: Articles in English from MEDLINE. The following terms were used: corticosteroids, inhaled corticosteroids, asthma, children, beclomethasone, fluticasone, budesonide, ciclesonide, growth, adrenal insufficiency, bone mineral density, and oral candidiasis. Treatment guidelines, review articles, controlled trials, meta-analyses, and systematic reviews evaluating the efficacy and the adverse events of treatment with ICS were selected. SUMMARY OF THE FINDINGS: In vivo and in vitro studies show that the available ICS have different pharmacokinetic and pharmacodynamic properties that result in different action potentials. ICS also differ as to the systemic and local side effects. The bioavailability of these products is essential in order to determine the incidence of side effects. In general, ICS are capable of controlling asthma, reducing the number of exacerbations, medical consultations, hospitalizations, and the need of oral corticosteroid (applications) bursts. Improvement can also be seen in pulmonary function, especially in patients with recent onset asthma. The most documented adverse effect is transitory decrease of growth rate. CONCLUSIONS: ICS are the main anti-inflammatory agent used to treat persistent asthma. When administered in low doses, they seem to be safe and effective. Patient monitoring allows for early detection of possible side effects associated with ICS.

[Atopic diseases in Brazilian children--etiologic multicentric study].

In order to determine the etiologic agents involved in atopic diseases in Brazilian children, we have performed this multicentric study in 8 areas in Brazil. We have done prick tests with inhalants and food antigens and analyzed skin tests results, considering positive the wheal mean diameter 3 mm. 22,2% of skin tests were negative and the majority were positive to inhalants: D.pteronyssinus(Dpt) (66.6%) and D. farinae(Df) (66.0%), house dust extract (29.0%), dogs epithelium (19.2%), cats epithelium (8.8%), feather (5.5%), molds (4.2%), Penicillium sp (2.2%) and Lollium perene (0.6%). We have had 9,1% of food positive tests: cow milk (5.2%), peanut (3.5%), corn (3.2%), cocoa and soya (2.2%), eggs and wheat (1.9%). We have concluded that the domestic mites are the most important agents involved in the etiology of atopic diseases in Brazilian children, and the extracts involved, in line with the sensitization of each geographical area.

O conhecimento de pediatras sobre alergia alimentar: estudo piloto

Objective: To evaluate the knowledge of Brazilian pediatricians about food allergy. Methods: Data was obtained from a sent back posted written questionnaire. It was fi lled in by Brazilian pediatricians, affi liated to the Brazilian Society of Pediatrics. Data was transcript to an Excel spread sheet and the frequency of affi rmative responses was reported as percentages. Results: Data from 895 written questionnaire of pediatricians from all over Brazil, (mainly from the southeastern region - 61.6%), were analyzed. The main clinical expressions of food allergy determined by the pediatricians were: respiratory, cutaneous and systemic symptoms (equal proportions). According to these pediatricians, cow’s milk (98.9%), egg white (58.7%) and peanuts (50.9%) were the main allergens related to food allergy symptoms. Although 74.8% of the responders have indicated food dyes and food additives as associated to food allergies, only 19.4% of them knew the identifi cation code of tartrarzine. Conclusions: The presented data reinforce the need to improve the pediatricians’ knowledge about the diagnosis and treatment of food allergy, in order to assure the use of appropriate diagnostic and treatment criteria.

The impact of the environment upon the respiratory tract

OBJECTIVES: Air pollution has been a significant worldwide problem with repercussions in the respiratory tract, along the years. The main objectives of this review are to present results from studies on the harmful effects of allergens as well as of pollutants over the respiratory tract.METHOD: Published studies were analyzed in respect to each agent involved, either environmental pollutants or allergens.RESULTS: There has been a remarkable increase in the prevalence of asthma and allergies in Western countries children, during the last decades, which involves participation of many environmental factors. The house dust mites allergens followed by pet allergens have been classified as one of the most important causes of early sensitization, in genetically susceptible individuals. It became of utmost importance to determine the action of pollutants in the airways of asthmatic patients, once asthma is an inflammatory disease with an outstanding surge of inflammatory cells, affecting airway mucosal. Among the environmental agents, tobacco smoke, NO(2), O(3) and the CO are associated to the increase in morbidity, with specific harmfulness.CONCLUSION: There are evidences that the higher exposure to indoor allergens, to pollutants and irritants, associated to changes in diets, changes in the exposure pattern to infectious agents and the use of antibiotics are leading to an increase in respiratory diseases over the last 30 years.

Duration of bronchodilator effect of inhaled Salmeterol (dry powder x metered dose inhaler) in children with acute asthma attack

Patients during a mild to moderate acute attack of asthma (FEV1: 50 - 80% of predicted) were treated with Salmeterol MDI - 50mcg or Rotadisk - 50mcg or Salbutamol (MDI -200mcg). The children were followed by Spirometry, measuring FEV1 (basal) and after treatment: at 30 minutes, 60 minutes and thereafter every 60 minutes until 780 minutes, if the patients maintained the FEV1 above 80% of the predicted value and/or an increment of 20% in the VEF1 basal value. The Salmeterol group showed a significant bronchodilation at 60 minutes which was maintained in half of the patients up to 9 hours. This was not observed in the Salbutamol group: the peak bronchodilatation was observed at 30 minutes and the bronchodilation effect was observed in half of the patients up to 6 hours. There were no significant differences between both presentations of Salmeterol. This drug allowed a prolonged bronchodilator effect and is, according to the several consensus on management of asthma, an adequate option in the treatment of moderate to severe asthma.